Intrauterine adhesions following fibroid surgery: incidence and prevention strategies. A systematic review.

Introduction: The purpose of this review was to provide current evidence of the relationship between fibroid surgery (hysteroscopic, laparoscopic/robotic, open) and the formation of intrauterine adhesions (IUA).

Evidence acquisition: A systematic electronic literature search was conducted to provide a survey of the various surgical modalities and their relevant incidence of intrauterine adhesions. Utilizing PRISMA methodology the search identified 23 full text original studies that were included in the analysis.

Evidence synthesis: Our analysis identified 2437 cases reported in the international literature whereby the de novo formation of IUAs were systematically assessed with second look hysteroscopy at least 4 weeks and usually up to 3 months after the surgery. In our analysis, out of 1678 hysteroscopic cases the mean incidence was 9.4% for all different techniques, including monopolar or bipolar diathermy, cold loop and radio frequency ablation. The reported numbers for laparoscopic/robotic and open surgery were 399 and 360 cases respectively. The incidence of IUA following endoscopic abdominal surgery was 12.8% and for the traditional open approach (laparotomy) was 18.3%. There is substantial heterogeneity on the reported data regarding risks factors contributing to IUAs; such as fibroid size, location, number as well as uterine cavity breach during abdominal surgery (either open, laparoscopic or robotic).

Conclusions: Iatrogenic IUAs following myomectomies are not uncommon and may be implicated in patient morbidity and sub fertility. Further studies are necessary to evaluate the prevention of such sequelae and improve therapeutic outcomes following fibroid surgery.